MEDICARE: EZ GRACE RESIDENTIAL HOME CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	106661	TX
2	3104A0630X	Assisted Living Facility (Behavioral Disturbances)	106661	TX

General Provider Information

NPI Number	:	1659818235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EZ GRACE RESIDENTIAL HOME CARE

Provider Business Mailing Address
First Line	:	919 SADDLEBROOK DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-1630
Country	:	US
Telephone Number	:	210-994-8210
Fax Number	:

Provider Business Practice Location Address
First Line	:	919 SADDLEBROOK DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-1630
Country	:	US
Telephone Number	:	210-994-8210
Fax Number	:

Authorized Official
Title or Position	:	FACILITY ADMINISTRATOR
Name	:	VICTORIA DELANO
Credential	:	RN
Telephone Number	:	240-478-0095

Provider Enumeration Date	:	01/20/2017
Last Update Date	:	01/20/2017

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